O0110D3a. Treatment: Suctioning- As needed- Adm, Step-by-Step

Step-by-Step Coding Guide for Item Set O0110D3a: Treatment: Suctioning - As Needed - On Admission

1. Review of Medical Records

• Objective: Identify any instances where PRN suctioning was initiated upon the resident's admission.
• Action Steps:
  • Thoroughly review the resident's medical records upon admission, focusing on physician orders, nursing assessments, and respiratory therapy documentation.
  • Look for documentation specifying the initiation of as-needed suctioning, including the method (oral, nasal, tracheal), clinical indications, and any specific conditions under which it should be performed.

2. Understanding Definitions

• Suctioning (As Needed/PRN): A procedure performed to clear the airways of secretions or blockages, executed based on the resident's immediate needs rather than at scheduled intervals.
• On Admission: Refers to treatments initiated within the 7-day look-back period from the resident's admission date.

3. Coding Instructions

• Action Steps:
  • Code this item as present if suctioning on an as-needed basis was ordered and initiated within the 7-day look-back period from admission.
  • Document the specifics about the PRN suctioning as prescribed, including indications for its use.

4. Coding Tips

• Ensure that the documentation from the admission clearly indicates PRN suctioning was to be performed, distinguishing it from scheduled suctioning.
• Verify that clinical indications for PRN suctioning are well-documented, providing clear criteria for when the procedure should be executed.

5. Documentation

• Essential Elements:
  • Clearly document the medical justification for PRN suctioning, including specific conditions or situations necessitating this approach.
  • Include detailed notes on the prescribed method of suctioning, any specific equipment used, and instructions for staff on recognizing the need for suctioning.

6. Common Errors to Avoid

• Incomplete Documentation: Failing to provide sufficient details on the conditions warranting PRN suctioning, leading to potential confusion or misapplication of the treatment.
• Misclassification: Incorrectly coding PRN suctioning as scheduled or vice versa due to unclear documentation or misunderstanding of physician orders.

7. Practical Application

Example Scenario: Upon admission, a resident with advanced COPD is assessed for risk of pulmonary secretions leading to airway obstruction. Given the potential for acute episodes of dyspnea, the attending physician prescribes oral suctioning to be performed as needed, based on specific signs such as audible secretions or visible distress. Nursing documentation includes detailed criteria for initiating suctioning, emphasizing careful monitoring of the resident's respiratory status.

Please note that the information provided in this guide for MDS 3.0 Item set O0110D3a  was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.